Delayed Smoking Cessation Improved Alcohol Treatment


SAN JUAN, P.R. – People in intensive alcohol treatment programs are more abstinent if smoking cessation efforts are delayed by 6 months, according to a study.

Smoking is common among people with alcohol dependence, with an estimated 60%-90% prevalence. And because smoking causes a lot of morbidity and mortality in such patients, it is a “compelling issue to work on in recovery,” Anne Joseph, M.D., said at the annual meeting of the American Academy of Addiction Psychiatry.

Although the results of nonrandomized studies suggest that smoking cessation efforts during intensive alcohol treatment are better than doing nothing, these trials included small numbers of participants and demonstrated only a modest benefit to nicotine replacement in this population.

For a more definitive answer, Dr. Joseph and her colleagues performed a large, 18-month, randomized trial. They hypothesized that concurrent treatment would improve both smoking and alcohol abstinence outcomes (J. Stud. Alcohol 2004;65:681-91).

“Here comes the surprising, but unfortunate, news,” said Dr. Joseph of the department of medicine at the University of Minnesota, Minneapolis. Alcohol abstinence was better when the smoking intervention was delayed by 6 months, compared with addressing both concerns simultaneously.

There were significant differences in outcomes at 6, 12, and 18 months. At 6 months, 64% of the delayed intervention group achieved 30-day alcohol abstinence, compared with 51% of the concurrent group; at 12 months, success rates were 53% and 46%, and at 18 months the rates were 60% and 48%.

The researchers also assessed alcohol abstinence 6 months after initiation of the smoking intervention in each group. Fifty-six percent of the delayed group were abstinent for alcohol for 6 months, compared with 41% of the concurrent group. At 12 months, 6-month abstinence was 42% versus 33%, and at 18 months, the rates were 48% and 41%.

Based on these findings, “delayed smoking cessation should be offered,” Dr. Joseph said.

Why the delayed intervention group fared better is unknown. It may be that there is an interaction between smoking and alcohol interventions, confounded by a specific biologic or behavioral factor. It could also be that adding anything to alcohol treatment worsens outcome, said Dr. Joseph, also of Minneapolis Veterans Affairs Medical Center.

The investigators randomized 251 participants to concurrent alcohol and nicotine treatment and 248 to initial alcohol treatment followed by delayed smoking cessation treatment. The Timing of Alcohol and Smoking Cessation (TASC) trial included people from three residential, day, and outpatient rehabilitation programs in Minnesota offering 3-5 weeks of intensive intervention with aftercare.

The concurrent group completed the smoking intervention at 12 months and the delayed group completed it at 18 months. Participants were 21-75 years old, about two-thirds were male, and one-third had a high school education or less. They smoked at least five cigarettes per day, but most had significant nicotine dependence, indicated by an average score of 6 on the Fagerstrom Test for Nicotine Dependence. There were an average of three previous smoking quit attempts. About half reported alcohol abuse alone, the remainder had one, two, or three other substance abuse issues.

The smoking cessation intervention included behavioral treatment and nicotine replacement therapy (to avoid withdrawal effects). One hour of behavioral treatment at baseline was followed by three follow-up sessions either in person or via telephone.

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